Session 13: Foot/Ankle and Trauma

Mette Frank Fenger¹, Per Hviid Gundtoft², Nanna Rolving¹, Louise Mortensen¹
1. Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital 2. Department of Orthopaedics, Aarhus University Hospital

Background: Treatment strategies for Achilles Tendon Rupture varies considerably. At Aarhus University Hospital, patients treated conservatively for achilles tendon ruptures follow a restrictive regime with immobilization for 11 weeks with late weight bearing (after 10 weeks) and no motion of the ankle during the treatment period.
Aim: To test the following hypothesis. A restrictive regime for Achilles Tendon Ruptures result in: 1. Low rate of re-rupture 2. Better Achilles Tendon Rupture Score (ATRS), due to smaller risk of elongation.
Materials and Methods: This was a questionnaire-based cross-sectional cohort study including patients with conservatively treated Achilles tendon rupture treated at Aarhus University Hospital between January 1, 2020 and July 31, 2022. A questionnaire including the ATRS was sent electronically to patients treated conservatively at AUH within the past 24 months. Additionally, patients were asked about reruptures, non- healed tendons, deep venous thrombosis and work status. ATRS scores were compared to data from Danish Achilles Database (DADB), which included patients, who follow a more liberal regime.
Results: Out of the 110 patients that received a questionnaire 100 responded. 83% were male and mean age was 55.6. The cohort was divided into three groups based on time from Rupture to questionnaire: group 1 (6-12 months) consisted of 36 patients, group 2 (12-24 months) consisted of 30 patients, and group 3 (>24 months) consisted of 34 patients. The mean ATRS scores were 49.0 in Group 1, 48.7 in Group 2, and 60.9 in Group 3. In DADB scores for similar patient groups were found to be 48.7, 57.7 and 64.0. Four patients (4%) had a rerupture, four patients (4 %) had a non-healed achilles tendons, and four (4%) patients experienced a DVT.
Interpretation / Conclusion: Assuming a minimal clinical important difference of 8 points on ATRS, we found no benefits in regards to neither ATRS scores nor reruptures between our study populations with a restrictive regime compared to group with a less restrictive regime.

Mick Nielsen¹, Jens Kurt Johansen², Anna Kathrine Pramming³, Jeannette Østergaard Penny⁴
1. Department of Orthopaedic, University Hospital Zealand; 2. Department of Orthopaedics Copenhagen university hospital Hvidovre; 3. Department of Orthopaedic, University Hospital Zealand; 4. Department of Orthopaedic, University Hospital Zealand;

Background: The European foot and Ankle Society has developed the 6 question EFAS score, as a common European Patient reported outcome measures (PROM) covering patients with foot and ankle pathologies.
Aim: To translate and adapt the EFAS score into Danish. Furthermore to perform a validation, reliability and responsiveness testing of the new score.
Materials and Methods: Translation and adaptation in accordance with guidelines from Beaton et. al. 2000 We aimed for 100 foot and ankle patients, 50 of those as test-retest. Control group of 70 foot- healthy individuals was planned. Patients filled out pre- and 6 months post- surgery evaluation of the EFAS-DK score. Statistics: Validity: Floor, ceiling effect, Effect size (ES) EFAS-DK more than 0.8. and large difference between patient and control was expected. Reliability: precision, test-re-test ICC, Measurement error and smallest detectable change (SDC) Responsiveness: effect size and minimal important change (MIC). Interpretability: SDCResults: No major challenges were encountered during the translation process. We included 123 patients, 96 of those completed the scores. Females/male: 64/32, age mean/median: 58/59, 20 to 85 years. 47 completed the test-retest. 66 controls included, age mean/median 51/52 (23-79). 45 returned the 6 months evaluation. EFAS-DK mean(SD) range. pre-operative: 8,5(5,4) 0 to 24, 6 months post-op: 14,0(5,3) 1 to 24, Controls baseline: 22,8 (1,8)17 to 24. Mean changes in total EFAS-DK score pre-to- post-op was 5,5. test-re-test: 0,1 Controls -0,5. Floor/ceiling effect for preoperative patients 2/96 and 1/96, for controls 0/45 and 27/45. Effect size EFAS-DK patient: 1,0 Effect size EFAS-DK control 0.3 Test-retest ICC; 0.93, Measurement error 1,37 and SDC: 3,2 MIC:1,5 EFAS points.
Interpretation / Conclusion: The ES is large for patients and low for controls. Low floor and ceiling effect. The ICC demonstrates excellent reliability. As for responsiveness the SDC by the patient was higher than the MIC which may reflect a weakness in our anchor questions. Overall, the EFAS-DK score seems to reliably identify relevant changes. Half the patients felt a large improvement in their foot, but as a general their operated foot are far from normal at 6 months postoperative.

Michael Rindom Krogsgaard¹, Henrik Palm¹, Kenneth Obionu¹, Yvette Astrup Cramer¹, Naja Bjørslev Lange¹, Tobias Haak¹, Christian Dippmann¹
Department of Orthopedic Surgery, Bispebjerg and Frederiksberg University Hospital, Copenhagen, Denmark.

Background: 40 % of patients with chronic ankle instability have pathology of the deltoid ligament (DL), and DL reconstruction (DLR) can be indicated. DL instability can lead to ankle OA. Series after DLR are small.
Aim: Long-term follow-up of DLR in a large group of patients.
Materials and Methods: During the primary operation an ankle arthroscopy had been performed to visualize the DL, and other relevant pathologies were also treated surgically. 503 consecutive patients (524 ankles) who had a DLR 2010-2018 were due to patient complaints invited in sept-nov. 2021 to answer postoperative period questions, complete the questionnaire FAAM and a ROM (range of motion) scale, and answer a number of anchor questions – and were offered optional physical control. On Jan 12, 2022 a TV-program and newspaper articles on this cohort was alleging the possibility of malpractice. For risk of bias, it was decided to close the link to collection of patient-responses the day after.
Results: 342 had a history of a trauma to the ankle and 105 had previous ankle surgery. In 447 the operating foot surgeon evaluated the MRI as showing signs of a pathology to the DL. 421 feet (80%) had procedures in addition to DLR. A total of 269 (53.8%) patients responded to the invitation prior to the release of critical press coverage. 11 indicated that they did not wish to participate. For 71% the operation solved their ankle-problems, for 11 % it made no change and for 19 % the condition became worse. 163 (63 %) were satisfied with surgery and 87 (34 %) were dissatisfied. 63 % would repeat the operation, 11 % might choose operation and 21 % would not. 67 % had pain in the ankle during the past week, and 50 % were not able to run. The mean score of the FAAM ADL scale was 44 (vs. 58 in a group of healthy persons), and the FAAM Sport scale 13 (vs. 24). Mean ADL ability (scale 0-100) was 72 (vs. 89) and mean sports ability 53 (vs. 87).
Interpretation / Conclusion: The relatively high degree of satisfaction in our cohort despite suboptimal clinical results (50 % are unable to run) probably reflects the complex nature of pathology in the DL insufficient ankle. There is a need for structured scientific evidence to establish principles for treatment.

Bjørn Nedergaard^1,2, Torben Stryhn^1,2, Bjarke Viberg^1,2
1. Department of Orthopaedic Surgery and Traumatology, Lillebaelt Hospital Kolding 2. Department of Orthopaedic Surgery and Traumatology, Odense University Hospital

Background: New generation Nitinol staples are easily implanted and are increasingly used in foot and ankle surgery. However, data regarding complications and reoperation rates when compared to standard treatment with screws and plates are scarce.
Aim: To assess reoperation rates after fixation with Nitinol staples in comparison to screws and plates in arthrodeses or osteotomies (A/O) of the foot.
Materials and Methods: This is a single center retrospective cohort study. Patients who had A/O with Nitinol staples, screws or plates in their feet from 01.08.2017 to 14.10.2020 were identified through the hospitals administrative database. Choice of implant was by the surgeon´s discretion. A/Os where a choice between staples, screws or plates was not relevant were excluded (e.g. subtalar arthrodesis). Patient files and x-rays were reviewed by two experienced foot and ankle- surgeons for surgical details and baseline clinical data. One year follow-up was conducted for reoperations. Descriptive statistics were applied.
Results: There were 395 patients with 486 A/O of the feet. Median age was 60 years (range 16-83) and 68% were females. The majority had an ASA score of 1 or 2 (83%), 7% had diabetes, 18% were smokers and 3% had alcohol overconsumption. There were 288 A/O treated with staples and 11.1% had a reoperation. Nonunions represented 3.1% while 5.9% were hardware removal. There were 73 A/O with screws and 20.5% had a reoperation. Nonunions represented 4.1% while 13.7% were hardware removal. There were 125 A/O with plates and 28.0% had a reoperation. Nonunions represented 8.0% while 16.0% were hardware removal. When assessing single joints, we observed reoperation rates of the 1st MTP-joint due to nonunion were 3.6% for staples, 4.2% for screws and 8.8% for plates. Reoperation rates of the 1st TMT-joint due to nonunion were 2.6% for staples and 7.5% for plates. Only 1 patient had surgery with screws only and no reoperation was observed.
Interpretation / Conclusion: A/Os in the feet with Nitinol staples seem to have few complications and low reoperation rates in comparison to plates and screws. Nitinol staples could be a future golden standard implant when performing arthrodeses and osteotomies in the feet.

Per Hviid Gundtoft^1,5, Julie Ladeby Erichsen², Mads Terndrup³, Lauritz Walsøe¹, Lasse Pedersen², Bjarke Viberg^2,4,5, Alice Ørts^2,4, Charlotte Abrahamsen^5,6
1: Department of Orthopaedic Surgery, Aarhus University Hospital 2: Department of Orthopaedic Surgery, Odense University Hospital 3: Department of Orthopaedic Surgery, Hvidovre Hospital 4: Department of Clinical Research, University of Southern Denmark, Odense, Denmark. 5: Department of Orthopaedic Surgery, Lillebaelt Hospital - Kolding, 6: Department of Regional Health Research, University of Southern Denmark

Background: In research studies of patients with ankle fractures several different patient reported outcome measures (PROM) have been used but few studies have compared them.
Aim: To compare patient preferences and psychometric properties of the Manchester Oxford Foot Questionnaire (MOXFQ), the Self-reported Foot and Ankle Score (SEFAS), the Olerud Molander Ankle Score (OMAS), and the Forgotten Joint Score (FJS) in adults with ankle fractures.
Materials and Methods: Patients with a surgically or non-surgically treated ankle fracture at three hospitals were included between 01.11.2018 to 31.08.2020. Patients received all four questionnaires 6-, 12-, 14-, 24-, 52-, and 104-weeks following the ankle fracture. Only fully completed questionnaires were included in the analysis. According to COSMIN guidelines, statistical tests were performed to assess structural validity, construct validity and reliability. Furthermore, floor- and ceiling effects were assessed at all time points. Content validity was assessed using cognitive interviews of nine patients, who were also asked to grade all four PROMs in order of priority.
Results: Each PROM was fully completed by 135 patients 12 weeks post-injury and by 111 at 14 weeks post-injury. When performing Confirmatory Factor Analysis, MOXFQ showed best model fit (CFI 0.946; TLI 0.936; RMSEA 0.08). When testing construct validity, all hypotheses were accepted except one as OMAS and FJS had a correlation of <0.7. All PROMs had an almost perfect test-retest reliability for the total score and for all domains. Interclass Correlation Coefficient 2.1 were between 0.81 to 0.91. Internal consistency measured by Cronbach's alpha ranged between 0.76 to 0.95 for the total scores and the domains. Only MOXFQ had an alpha of 0.69 for the domain social, which is below acceptable. The OMAS showed ceiling effect at 52-weeks and MOXFQ floor-effect at 104-weeks. Eight patients out of nine expressed that MOXFQ were the best or second-best at assessing their symptoms. Six patients scored SEFAS best or second-best.
Interpretation / Conclusion: All PROMs performed well in the psychometric evaluation. Patients rated MOXFQ and SEFAS highest. We recommend that MOXFQ should be used in future ankle fracture studies.

Christian Grundtvig Refstrup Rasmussen¹, Rasmus Elsøe¹, Christian Pedersen¹, Peter Larsen²
1. Department of Orthopaedics, Aalborg University Hospital; 2. Department of Physiotherapy, Aalborg University Hospital

Background: Ankle fractures are very common injuries. Following surgical treatment, inpatient care for 4-10 days is common. Several studies have reported that outpatient surgical treatment of ankle fractures is safe. However, the literature lacks high quality randomised controlled trials comparing inpatients and outpatient care.
Aim: The aim of this study was to investigate the feasibility of outpatient care for selected surgically managed ankle fractures and the setup of a randomized controlled trail comparing in- and outpatient care of ankle fractures with regard to patient reported outcome, patient satisfaction, adverse events, pain, function and healing.
Materials and Methods: This study is a proof-of-concept study as part of a non-inferiority randomized control design to compare in- and outpatient care of ankle fractures. Included were adult patients (>= 18 years), stable ankle fractures necessitating surgical treatment and able to ambulate with walking aid and perform adequate ADL at home. Feasibility was based on two questions regarding patients experience with the treatment and the absence of any serious adverse events. Clinical results were obtained at 2 days, 2, 6 and 12 weeks and included pain, range of ankle motion (ROM), healing, Foot and Ankle Outcome Score (FAOS), European Quality of life 5 Dimensions questionnaire, (EQ5D-5L), workforce and Tegner Activity level. Adverse events were reported throughout the study.
Results: A total of 76 patients were accessed for eligibility and 22 patients were included. 49 patients were excluded, and 6 patients did not want to participate. The most common reasons for exclusion were: 22 patients were not able to ambulate with walking aid and perform adequate ADL at home and 15 patients were not stable in preoperative cast. The median age was 48.6 with and range from 18 to 77. Female sex represents 52%. Patient reported experience and satisfaction response completeness: 2 weeks – 17/22, 6 weeks 17/22 and 12 weeks 19/22.
Interpretation / Conclusion: Results indicate that a full RCT comparing in- and outpatient care of ankle fractures is feasible without adjustments of the protocol. High completeness in the planned follow-up procedure was observed.

Louise Thuren Jørgensen ¹, Christian Cavallius², Nikoline Møller Lynnerup³, Ole Brink⁴
1. Ortopædkirurgisk afd. M, Bispebjerg Hospital. 2. Ortopædkirurgisk afd. O, Odense Universitetshospital. 3. Ortopædkirurgisk afdeling. Herlev Hospital. 4. Ortopædkirurgisk afdeling. Århus Universitetshospital.

Background: Immobilization due to ankle fracture increases the risk of venous thromboembolism (VTE) including deep vein thrombosis (DVT) and pulmonary embolism (PE). There’s no national Danish guideline about the use of thromboprophylaxis with low molecular weight Heparin (LMWH) when immobilizing patients due to ankle fracture, and current international guidelines disagree whether or not to use thromboprophylaxis.
Aim: The purpose of this short clinical guideline is to review current literature on the subject and to offer support when deciding for or against thromboprophylaxis when immobilizing patients with a brace or cast due to ankle fracture.
Materials and Methods: A systematic search of relevant literature was conducted on Pubmed, Embase and Cochrane on March 9th, 2023. The evidence was rated by standardized forms (AMSTAR2, Cochrane Risk of Bias-tool and GRADE).
Results:From a total of 545 studies, 441 were excluded on titles and abstracts, and 97 studies were excluded after reading full text by at least two of the authors. Further two studies were excluded due to wrong study design, and one was excluded due to a low score on AMSTAR2. Of the remaining four studies, two were metaanalyses, and two RCTs that already were included in the two meta analyses. One meta-analysis showed significant lower incidence of asymptomatic DVTs, when using LMWH compared to placebo or no treatment (OR=0,48 (0,33;0,7)). The other meta-analysis showed significant lower incidence of symptomatic DVTs, when using LMWH compared to placebo or no treatment (OR 0,29 (0,09;0,95)). No clear differences were found between the LMWH and control groups for PE. Major adverse events were rare.
Interpretation / Conclusion: Low-quality evidence showed that the use of LMWH reduced the incidence of DVT when immobilizing the lower limb due to ankle fracture, when compared with no prophylaxis or placebo. Low-quality evidence showed no clear differences in PE rates. The quality of evidence was reduced to very low because of heterogenicity in inclusion criteria, treatment protocols and measurement of outcome in the studies included in the two metaanalyses, resulting in a high risk of bias.